Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0208X | Pediatric Infectious Diseases | 45625 | CO |
NPI | 1629124227 |
---|---|
Provider Name | Samuel Dominguez |
First Address | Aurora, CO 80040-0876 |
Second Address | Aurora, CO 80045-7106 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2007 |
Last Update Date | 04/01/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
84539747 | (05) | CO |